Fire on dive boat Conception in CA

[Wookie]

Other 2 crew not interviewed at behest of USCG, which seems weird to me since NTSB is lead agency.

I spoke to the CG lead fire investigator today. She teaches fire investigation at investigations school, she used to be my inspector for 3 years.

She was pulled off in favor of FBI and ATF. Which I maybe understand, but I’d think that the CGs lead fire investigator might add something, or learn something if not help.

 

[chillyinCanada]

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[Tug]

The COI has been floating around online:

https://ca-times.brightspotcdn.com/...5f54/conception-certificate-of-inspection.pdf

 

[bowlofpetunias]

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A ScubaBoard Staff Message...

This summary updated 14 Sept 2019 Updates are also posted on page one of this thread. Please follow links and read surrounding posts to keep up to date.

It is always best to read an entire thread before commenting. Due to the length of this one we are providing & updating this summary for topics covered. We believe this information is credible but it can not be established as proven facts prior to completion of the investigation.

Please be kind when you post here remember the special rules and consider families, friends and survivors who are reading this. Consider Accidents and Incident Threads: Victim Perspective

We can not determine the cause here but discussing possibilities may help to prevent future tragedies.

34 Casualties DNA identified

• SB Sheriff Brown (Coroner) states probable COD smoke inhalation
• last victim found 11 Sept

Conception compliant met or exceeded applicable USCG requirements on last inspection implies approved; fire alarms, fire fighting equipment and escape routes

• Grandfathered for inspection requirements. Discussion here
• USCG issue Safety Information Bulletin 10 Sept 2019
  
• Certificate of Inspection here

NTSB (National Transportation Safety Board) Preliminary Report
Preliminary Report: Marine DCA19MM047
Discussion points

• concludes all crew sleeping
• Statement in Preliminary Report says it may contain errors

Anchor Watch

• Captain's responsibilities
  
• Regulations
  
• Anchor watch process discussion
• People from prior trips reported meeting the "watchman" at various times during night

Rough time line as reported

• night dive time? commonly done by passengers; NO night dive by Crew
  
• 2:30 crew member finished up in the galley verified heating elements were out and cold etc. Then went upstairs to bed. Not indicated if this was the designated Anchor Watch see
  
• Between 3 and 3:14, a crew member awoke hearing a bang. He attempted to go down to investigate but stairs already afire.
• 5 crew were in the wheelhouse two levels above the berth area. 1 crew member in the berth below did not survive.
• crew jumped to deck, one broke leg other undisclosed ankle injuries
• Captain first Mayday from Bridge documented 3:14
• crew tried to reach the passengers from aft passage into the salon/galley then via forward front windows
  
• forced from the boat by the fire some swam aft to the dingy & brought it alongside to rescue injured crew
  
• sought help from nearby vessel Grape Escape Another Mayday call.

Most suspected causes of fire discussed

• charging batteries either in the Galley or possibly berth area
• Dept of Fire Protection Engineering, U of Maryland video
  
• electrical fires are often a factor
  
• boat fires DO burn quickly
• electrical wiring faults inside walls can smolder for hours before bursting into flame
• Boat USA Foundation boat fire video

Battery discussions here

Original location of fire not yet established

• former owner believes it started in passenger berth area
• some believe it started in galley/salon area

Conception's layout and facilities

• all electric no propane or other fuel used for cooking
• Nitrox = Nuvair Membrane
• NO banked Oxygen
• all O2 First aid tanks or stage bottles were aft (last to burn)
• Conception Safety Video link
  
• Post fire picture
• News footage raising the Conception

Exits from Dorm

• main exit - stairs to starboard forward end of the dorm to the galley/salon.
• emergency hatch above bunks at aft end of dorm exited in aft portion of the salon, just inside the passageway to the after deck.
• no locked doors to the galley, salon or berth area.

The design of berth area and escape hatches discussed extensively. It meets current USCG standards which many believe may be changed as a result of this tragedy.

Excellent DAN article Mental Health post incident

Google Map link that shows Platt Harbor and the US Coast Guard Station, Channel Islands. Ventura and Santa Barbara are to the north

Related threads

A personal perspective on California Live-aboards
Discussion of legal aspects here
Condolences posted here
Donations here

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[chillyinCanada]

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A ScubaBoard Staff Message...

The A&I subforum is more 'normally' the platform for discussing diving accidents. THIS thread is NOT about a diving accident.

It is about a tragic loss of lives aboard a dive boat.

We are all affected deeply but there are those that are affected more intimately than most of us here. Families have lost their loved ones and in a horrific way.

Please please don't make it worse for them. Consider your words carefully.

There's been a tremendous amount of deletion and editing of this thread, especially since this afternoon upon release of the NTSB preliminary report.

You may or may not have received notice of deletion of your post. Some posts may be returned to the thread after further review. Don't count on it.

A number of posts were moved to the Legal subforum, so look there too

Legal considerations for the Fire on dive boat Conception in CA

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[KevinNM]

The Latest: All 34 victims of California boat fire ID'd

 

[CaptHobbes]

I believe that is correct. My current understanding is that what I've marked red in the picture is the engine room, orange is the bunkroom, and green is the head. (apologies for the crude markup, it should be taken as a sign only of my limited abilities, not a lack of seriousness). The only thing I feel confident saying based on this understanding is that the fire didn't start in the head

Yes, the markup is overall correct. The space in the bow forward of the shower stalls was not really part of the shower room (there were no toilets, so I'm not calling it the head) and not connected to it.

I'm no fire investigator, but I expect after a fire of this magnitude the heaviest burned area would be one with the greatest amount of combustible materials and air circulation, which may or may not be the place where the fire started. I doubt anything conclusive could be said based just on this photo.

 

[SapphireMind]

Technically, they would only need to interview one crew member to know the others were asleep: The one who initially responded to the sound/fire. If he had to go wake up other crew members in their berths, that would mean they were not roving or awake.

 

[chillyinCanada]

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A ScubaBoard Staff Message...

Accident analysis is the business of identifying mishap causes and recommending actions to prevent a repeat mishap.

Who's to blame doesn't matter.

The laying of blame, extraction of justice, punishment, liability, etc - all these are the business of the courts (and to satisfy our inner need for balance and justice in the universe), but they don't really address mishap prevention. Mishap prevention involves actions.

Example:
Lets say the causes of a mishap are all actions taken by a boat's captain.

Mishap analysis would identify those actions as causes, and recommend other actions that would prevent (or greatly reduce the chance of) the mishap in the future. Nothing about liability, fault, blame, punishment etc would be addressed in the mishap analysis because those are not actions that would prevent the mishap.

Example: "The boat didn't have enough fuel on board to conduct a search." might be identified as a cause of a mishap, and mishap analysis would recommend "that a boat always carry enough fuel to conduct a search" on every dive. Why the boat didn't have enough fuel, who made the decision to carry too little fuel, whose fault it is that the boat had too little fuel, etc, are all questions for regulators and courts, not mishap analysis. And it may be that there's no blame anyway - it could be that a new standard needs to be set because this mishap revealed a flaw in the current standard.

The general theme of mishap analysis is that all mishaps are preventable, even when no one is at fault. For example, all diving mishaps are preventable by not diving in the first place.

Mishap analysis doesn't waste time asking "what was he thinking?" either, but rather asks "what did he do?" We can agonize all day long about why Joe didn't ditch his weights when ditching his weights would have saved him, but it doesn't really matter. The action that will prevent a repeat of Joe's mishap is "ditch weights."
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What we're trying to do in the A&I forum is to provide a forum for a Safety type analysis of mishaps; to identify actions that lead to mishaps and actions that can prevent mishaps. The mishap analysis mindset is difficult for those who lack formal training in it, as our natural tendencies are to find out who or what to blame and seek justice.

Just remember that justice isn't going to prevent future mishaps. It is changes in behavior that prevents recurrence of mishaps.

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[vlxjim]

There is no kitchen-stove area in the photo. You are seeing the inside of the hull below the main deck. The galley with the stove was at the main deck level, and it's completely gone. The dark structure in the middle of the bow area you see are the shower cabins. I'm guessing the backsplashes were made of something less combustible, perhaps enameled metal--I never really paid attention--that's why they are still standing. The open space aft adjacent to them is the shower anteroom, which had a counter on the port side with two sinks. The galley stove was somewhere above this area.

There seems to be some confusion about "the engine room", possibly because of the LA Times diagrams showing the entire area aft of the bunk room as the engine room. There were actually two compartments aft of the bunk room, separated by a bulkhead you can see in the picture aligned with the leftmost cargo sling. The forward compartment is the actual engine room. I'm assuming that the two smaller structures inside, the port one with a hose draped over it, are the diesels. The rear compartment was a drying room, with a rack the port side to hang drysuits and wetsuits overnight. There was also a regular dryer, and in more recent years a Nuvair nitrox compressor.

I believe that you are correct. Those are the diesels you can make out the turbos.